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GLOBAL
VOLUME 21
March
S MART
UPDATE
Understanding the
global opioid crisis
EN
ES
Research 2019
GLOBAL
SMART
UPDATE
About the SMART Update Content
Synthetic drugs constitute one of the most significant Understanding the global opioid crisis 3
drug problems worldwide. After cannabis, amphetamine- What are opioids? 3
type stimulants (ATS) are the second most widely used
drugs across the globe, with use levels often exceeding How do opioids affect the human body? 3
those of heroin and/or cocaine. Along with ATS, the The risk of opioid overdose 4
continued growth of the new psychoactive substances Risks of non-medical use of opioids 4
(NPS) market over the last years has become a policy
challenge and a major international concern. A growing Understanding the current opioid crisis 4
interplay between these new drugs and traditional illicit The scope of the global opioid crisis 6
drug markets is being observed. By December 2018, the
emergence of NPS had been reported by 113 countries AFRICA
and territories. Trends on the synthetic drug market Africa 6
evolve quickly each year. Middle East, North Africa and West Africa 6
The UNODC Global Synthetics Monitoring: Analyses, Nigeria 6
Reporting and Trends (SMART) Programme enhances Ghana 6
the capacity of Member States in priority regions to AMERICAS
generate, manage, analyse, report and use synthetic United States 7
drug information to design effective policy and pro-
Canada 7
gramme interventions. Launched in September 2008,
the Global SMART Programme provides capacity building Mexico 7
to laboratory personnel, law enforcement and research ASIA
officers in the Pacific, East and South-East Asia, South China 8
Asia, the Near and Middle East, Africa, Latin America India 8
and the Caribbean; and regularly reviews the global
Japan 8
amphetamine-type stimulants and new psychoactive
substances situation. Its main products include online EUROPE
drug data collection, situation reports, regional assess- Europe 8
ments and the UNODC Early Warning Advisory (EWA) Estonia 8
on new psychoactive substances. The EWA is a web- Spain 8
portal that offers regular updates on new psychoactive
substances, including trend data on emergence and OCEANIA
persistence, chemical data, supporting documentation Australia 8
on laboratory analysis and national legislative responses New Zealand 8
(available at: www.unodc.org/nps). INTERNATIONAL
The Global SMART Update (GSU) series is published UNODC 9
twice a year in English, Spanish and Russian. It provides WHO 9
information on emerging patterns and trends of the
global synthetic drug market in a concise format. Each Options for response to address 9
issue of the Global SMART Update contains a special seg- the opioid crisis
ment and short segments on the topic of interest.1 Past National and international control measures 9
issues have covered topics such as methamphetamine Identification and detection of 10
continuing to dominate the synthetic drug market, the synthetic opioids
shift in the synthetic drug market, non-medical use of
benzodiazepines, the fentanyl group of synthetic opi- Early warning systems 10
oids, UNGASS 2016 recommendations and the injecting Public health and prevention 10
use of synthetic drugs. Electronic copies of the Global The way forward 11
SMART Updates and other publications are available
at: www.unodc.org/unodc/en/scientists/publications-
smart.html.
1 The information and data contained within this report are from official
Government reports, press releases, scientific journals or incidents con-
firmed by UNODC Field Offices. This report has not been formally
edited. The contents of this publication do not necessarily reflect the views
or policies of UNODC or contributory organizations and neither do they
imply any endorsement. Suggested citation: UNODC, “Understanding
the global opioid crisis”, Global SMART Update Volume 21, March 2019.
2
Volume 21
Understanding the global opioid crisis
The non-medical use of opioids presents a significant concern for public health, safety and law enforcement
authorities worldwide. In the past years, the non-medical use of potent opioids such as fentanyl and its ana-
logues have been reported mainly from North America, as well as from Asia, Europe and Oceania. Often sold
as heroin or prescription medicines, these substances have contributed to the unprecedented number of re-
cent opioid overdose deaths. The non-medical use of tramadol, an opioid analgesic, continues to increase in
parts of Africa and the Middle East with reported adverse health effects. The rapidly emerging crisis which
has resulted in significant harm to human health and welfare, including fatalities, calls for a coordinated, com-
prehensive and multidisciplinary response, which addresses public health and safety, and encompasses both
demand and supply reduction initiatives, while promoting access and availability of opioids for medical and
scientific purposes.
What are opioids?
Opioids1 is a generic term applied in palliative care, diacetylmorphine receptors and the mu-opioid recep-
to a variety of substances ranging (heroin). However, approximately tor which is extensively present in
from the naturally-occurring opiates, 75 per cent of the world population, the brain, brainstem and spinal
such as opium and morphine, to predominantly in lower-income cord, is responsible for triggering
synthetic opioids, such as fentanyl countries, is left with limited or no the brain reward system and pro-
and tramadol, and semi-synthetic access to proper pain relief.3 ducing pain relief by decreasing
opioids such as heroin, as well pain transmission.4 The location of
as new psychoactive substances How do opioids affect the opioid receptors in specific parts
(NPS) with opioid effects such as human body? of the body, such as the ‘respira-
acetylfentanyl.2 Opioids are widely While opioids may differ in how tory centre’ in the brain, intestines
used in medical practice because of they are produced, they all share and the peripheral neurons, means
their pain-relieving properties. The one common feature: their other effects such as suppression of
products range from preparations interaction with the opioid recep- breathing, constipation, and sensa-
of codeine or tramadol used for tors in the human body. There tions of warmth are associated with
the treatment of mild or medium are different types of opioid the use of opioids.
pain, through essential medicines
such as morphine, to very potent Figure 2: Effects of opioids on the human body
substances used in alleviating pain Pain relief,
following surgery such as fentanyl, or Triggers events which elicit the dependence
euphoria associated with the ‘high’
Figure 1: Common opioids
Respira�on center -
ac�va�on suppresses breathing
Suppress or stop the
breathing reflex - can lead to
brain damage, coma or death
Synthe�c Semi- NPS with Sensa�on of warmth
opioids used synthe�c opioid effects
in medicine opioids (no medical
use) Cons�pa�on
• Fentanyl • Heroin • Acetylfentanyl
• Tramadol • Oxycodone • Furanylfentanyl
• Methadone • Hydromorphone • U-47700
• Buprenorphine • AH-7921
3 INCB (2015), Availability of Internationally
1 For the purpose of this report, opioid receptor Controlled Drugs: Ensuring Adequate Access
agonists will be termed “opioids”. for Medical and Scientific Purposes Indispen-
2 UNODC (2016), Terminology and Informa- sable, adequately available and not unduly 4 UNODC (2016), Terminology and Informa-
tion on Drugs. Available at: https://www. restricted. Available at: https://www.unodc. tion on Drugs. Available at: https://www.
unodc.org/documents/scientific/Terminol- org/documents/drug-prevention-and-treat- unodc.org/documents/scientific/Terminol-
ogy_and_Information_on_Drugs-3rd_edition. ment/INCB_Access_Supplement-AR15_avail- ogy_and_Information_on_Drugs-3rd_edition.
pdf ability_English.pdf pdf
3GLOBAL
SMART
UPDATE
The risk of opioid overdose and overdose deaths - have played increases in street level purity of
Opioids differ in terms of their onset a significant role in the selection of opioids (e.g. high purity heroin) and
and duration of action, potency and opioids for medical use. For example, loss of tolerance in cases of relapse
the amounts required to produce out of scores of fentanyl derivatives after a period of abstinence are illus-
the same desired action. Chronic evaluated for medical use in humans trations of scenarios which expose
use of opioids leads to tolerance since the early 60s, only four (fen- opioid users to an increased risk of
and dependence, which means users tanyl, sufentanil, alfentanil and overdose. Uncontrolled dosages and
require a larger amount of the same remifentanil) are currently licenced frequency of use can greatly exacer-
substance, or more potent sub- for medical use. In the last years, bate the risks associated with opioid
stances, to produce similar effects. opioid overdoses in North America use. Tolerance and dependence may
The predisposition of opioid users to have claimed tens of thousands of develop quickly, and reach extreme
‘overdose’ is influenced by the type lives annually. levels. Most significantly, each epi-
of opioid, particularly in terms of its sode of non-medical use carries a
potency, dose, route and frequency
Risks of non-medical use high-risk of overdose and death
of administration, and co-admin-
of opioids because of respiratory depression.
istration of depressants such as The non-medical use of prescription Due to the way opioids work, stop-
alcohol, benzodiazepines or other drugs can be defined as the taking of ping the use of these drugs following
opioids which produce a synergistic prescription drugs, whether obtained dependence can result in ‘with-
effect. In the United States, opioid by prescription or otherwise, other drawal’ symptoms such as vomiting,
overdoses have contributed to a than in the manner or for the rea- diarrhoea, uncontrollable shaking,
decline in average life expectancy sons or time period prescribed, or by cramps, chills, panic and fever.9
for the second time in three years, a person for whom the drug was not
prescribed.8 The non-medical use
Understanding the current
from 78.9 years in 2014 to 78.6 years
in 2017.5 of opioids can have severe health opioid crisis
consequences and is a risk to public Recent years have seen a sharp rise
Opioid overdoses are caused by the
health. Inadvertent use of opioids of in opioid-related overdose deaths/
effect of opioids on the opioid-recep-
higher potency than intended, e.g. hospitalizations mainly in North
tors in the ‘respiration centre’ of the
oxycodone tablets containing fen- America, and to a certain extent
brain, whose activation can lead
tanyl, heroin laced with fentanyl or in Europe. Epidemics of overdose
to suppression or stopping of the
more potent analogues of fentanyl deaths associated with powerful
breathing reflex.6 This can result in
such as carfentanil, or unexpected synthetic opioids such as fentanyl
brain damage because of decreased
oxygen movement to the brain, in Non-medical use of illicit products Non-medical use of licit products
coma or even death. Substances such
as naloxone and naltrexone, prevent Uninten�onal consump�on when Licit product in country of
or reverse the activation of the mu- found as adulterant in other illicit produc�on but not approved for
drugs/counterfeit medicinal medical use in country of sale,
receptors by opioids and allows the products used for non-medical
person to breathe again.7 They play BLACK MARKET purpose, smuggled, for
black market
an important role in the emergency
treatment of persons experiencing ? BLACK MARKET (e.g. Tramadol)
a life-threatening opioid overdose. Resembles pharmaceu�cal SELECTED
The myriad of effects of opioids on
product but contains SUPPLY Licit product, but
other synthe�c opioids in obtained without
the human body and brain - some varying doses/composi�on, CHANNELS FOR prescrip�on from un-
desired, such as the relief of pain, illicit produc�on, not THE NON-MEDICAL authorized sources (Internet,
intended for medical use, illicit online pharmacies,
and some undesired, such as respira- black market
USE OF black market)
tory depression which leads to coma BLACK MARKET OPIOIDS BLACK MARKET
“Doctor shopping”
5 Murphy SL, Xu JQ, Kochanek KD, Arias E.
Sub-standard product (not Obtained under pretext of
(2017), Mortality in the United States, NCHS correct dose, contains unapproved medical purpose, with
Data Brief, no 328. Hyattsville, MD: National ingredients, incomplete prescrip�on, sold on black
Center for Health Statistics. 2018. Available labelling etc.), obtained for market
at: https://www.cdc.gov/nchs/data/databriefs/ non-medical purposes, smuggled, BLACK MARKET
db328-h.pdf for black market
6 WHO (2018), Information sheet on opioid
overdose, August 2018. Available at: https://
www.who.int/substance_abuse/information-
sheet/en/ 9 UNODC (2016), Terminology and Informa-
7 WHO (2018), Information sheet on opioid tion on Drugs. Available at: https://www.
overdose, August 2018. Available at: https:// unodc.org/documents/scientific/Terminol-
www.who.int/substance_abuse/information- 8 UNODC (2011), The non-medical use of ogy_and_Information_on_Drugs-3rd_edition.
sheet/en/ prescription drugs - Policy direction issues. pdf
4Volume 21
Figure 3: Factors influencing the current opioid crisis
• Availability on the Internet, dark web and street market • Facile and cheap synthesis
• Use of captivating marketing strategies via social • Used as highly potent adulterants in traditional
networking and other multimedia channels to illicit drugs
attract users
• Easy to conceal and traffic (highly potent
• Targets vulnerable groups substances require only small amounts)
• Existence of informal market for
• New formulations, including nasal
medicines
sprays
• High profitability for the illicit market
• Import of raw material and
• Involvement of old (organized Market local manufacture (e.g. tablet
crime) and new players
(“start-up” traffickers) Distribution Manufacture pressing)
• Desirable sedative, euphoric User Legislation • International and national
and other effects legislative gaps
• High dose preparations
Preferences And
• Lengthy national regulatory
(e.g. tramadol) Control processes for scheduling new
• Increased potency compounds
• Low price • Control vs access of opioids
• Lifestyle and “normalization” of use in society • Lack of field identification methods
• Reduced stigma on users (presentation as pills and • Low concentrations of highly potent substance pose
sprays) a challenge for identification
are not new. In the 1970s and 1980s, heroin or as counterfeit prescrip- Figure 4: Emergence of new
products containing fentanyl and tion drugs (e.g. fentanyl, oxycodone psychoactive substances
its analogues appeared on the illicit and benzodiazepines), without the with opioid effects
drug market in North America and user’s knowledge. In several regions 50 46
Number of NPS with opioid effects
Europe and became notorious for including Asia, Europe, North Amer- 45
accidental overdoses.10 While then, ica and Oceania, fentanyl analogues 40
the sharp rise in overdoses was and other synthetic opioids have 35
attributed to heroin, the current 30
also been found as contaminates 25 22
crisis is mainly attributed to clan- in cocaine, MDMA and metham- 20 15
destinely manufactured fentanyl,
phetamine. The mixtures of new 15
fentanyl analogues and tramadol. 10 6 8
synthetic opioids with illicit drugs 4
The perennial danger of opioids 5
can also be seen in international and their trafficking through global
0
supply chains, transforms this chal-
2012
2013
2014
2015
2016
drug control with almost half (46 2017
per cent) of all substances currently lenge into a fatal phenomenon with
under international control, belong- complex transnational linkages.
Source: UNODC Early Warning Advisory, 2018
ing to the group of opioids.
While the cause of the phenomenon,
and the challenges posed by these The need to prevent the poten-
Pills and powders containing fen-
fatalities are complex, more evi- tial dangers of abuse of opioids is
tanyl analogues sold on the illicit
dence is emerging about the role of reflected in the international drug
market pose a threat to public
fentanyl and its analogues as well as scheduling decisions taken during
health because of the variable
the last years. While the over 800
quantity and potency of the active other synthetic opioids in the current
NPS identified worldwide are mostly
components, which in extreme crisis in North America. Over the last
stimulants and synthetic cannabinoid
cases, such as with carfentanil, may decade, there has been a dramatic receptor agonists, eleven NPS with
be up to 10,000 times more potent increase in the number of NPS with opioid effects have been scheduled
than morphine. Such products can opioid effects detected across the between 2015 to 2018, including
prove particularly dangerous when world, with twenty-nine countries nine fentanyl analogues. This repre-
sold as street heroin, together with reporting the emergence of such sents the second highest scheduling
synthetic opioids. Between 2009 and within a group of substances, only
10 Henderson GL. (1991), Fentanyl-related 2017, a total of 62 NPS with opioid after the group of stimulants, with
deaths: demographics, circumstances, and
toxicology of 112 cases, Journal of Forensic
effects emerged, including 48 fen- 13 substances scheduled over the
Science, Mar 1, 36(2), 422-33. tanyl analogues. same period.
5GLOBAL
SMART
UPDATE
id c risis The scope of the global opioid crisis
al op i o The magnitude and tragic impact of the opioid crisis in North America
b
g lo Oceania have made global headlines, but this is not the only region where
opioids have become a concern.
t he
Asia
t of
fentanyl and Africa: High incidence of non-medical use of tramadol continues
its analogues
Americas
Exten
and increasing use of codeine-based cough syrup reported
fentanyl and
its analogues Americas: Fentanyl, fentanyl analogues and other synthetic
fentanyl and opioids mixed with heroin or other drugs leading to a high
its analogues Fast emerging number of fatal overdoses; and expanding opioid manufac-
Europe
public health ture with intra-regional trafficking
and Middle threats Asia: Indications of fentanyl and fentanyl analogues use and
heroin, fentanyl and manufacture of synthetic opioids
Near
Eas
Africa its analogues Europe: Main opioid of concern remains heroin, but increas-
t
ing reports of fentanyl, methadone and buprenorphine use
tramadol
tramadol and Middle East: Increase in tramadol use
codeine-based Oceania: Use of fentanyl and fentanyl analogues increasingly being
cough syrups
reported
Africa, North Africa and the Middle heroin and morphine have contributed
AFRICA East. The use of tramadol is perceived to opioid users shifting to cheaper and
to boost energy and improve mood. more easily available opioids.
Africa: Social implications of Typically, it is consumed with other UNODC (2019), Drug Use in Nigeria 2018.
synthetic opioids in the region substances, such as alcohol, energy Available at: https://www.unodc.org/docu-
drinks and other mind-altering drugs ments/data-and-analysis/statistics/Drugs/
The non-medical use of synthetic opi- Drug_Use_Survey_Nigeria_2019_BOOK.pdf
(e.g. cannabis and inhalants). However,
oids, particularly tramadol, is becoming
WHO studies show that the drug can
a growing concern in Africa, adding pres-
produce physical dependence, with this Ghana: High dose tramadol
sure on a strained health-care system,
dependence particularly when it is used was uncovered
which are struggling to meet the basic
needs of the population. Most of the daily for more than a few weeks. Authorities are reporting increasing
global seizures of pharmaceutical opi- UNDOC (2018), World Drug Report 2018 amounts of substandard or illicitly man-
oids were recorded in West, Central and - Analysis of drug markets. Available at: ufactured tramadol. Alarming quantities
North Africa, which accounted for 87 https://www.unodc.org/wdr2018 of tramadol tablets that contained active
per cent of the total seizures in 2016. ingredients exceeding the authorized
Women and young people seem to Nigeria: Increased misuse of medical dosages were uncovered in
be particularly affected by the crisis. tramadol and cough syrups Ghana, following a series of raids by
Moreover, these vulnerable groups are the Food and Drugs Authority. In 2017,
A steep increase in the non-medical
often exploited by local gangs or large authorities seized 524,000 tramadol cap-
use of prescription opioids, specifically
criminal organizations, which use them sules, with 40 per cent having a content
tramadol and cough syrups (contain-
as ‘mules’ for cross-border trafficking. of 120 mg of tramadol, 18 per cent with
ing codeine or dextromethorphan),
Although data is limited, robberies as 200 mg, and a 19 per cent with 225 mg
has been recorded in Nigeria accord-
well as rapes, gang violence, abduction per capsule. Only 13 per cent of the tra-
ing to the first-ever national drug use
and murder have been linked to such an madol seized had a typical content for
survey. Past year use of opioids in 2017
alarming trend. Additionally, increasing medical purposes of 50–100 mg per cap-
was estimated at 4.7 per cent (4.6 mil-
numbers of injuries and fatalities linked sule. About 87 per cent of the tramadol
lion people) and cough syrup at 2.4 per
to driving under the influence of trama- seized in 2017 originated in India. No
dol have been recorded. cent (2.4 million people). Prescription information is available on the manufac-
opioids were the second most widely ture, whether the seized packages had
UNDOC (2018), World Drug Report 2018 used drugs, after cannabis; and the
- Analysis of drug markets. Available at: been illicitly manufactured or diverted
https://www.unodc.org/wdr2018
most common drug injected with 1 out from licit manufacturing and where the
of 5 drug users becoming dependent. diversion took place.
Opioid use among men was at 6 per
Middle East, North Africa and UNDOC (2018). World Drug Report 2018.
cent compared to women at 3.3 per
West Africa: Non-medical use cent. The misuse of cough syrups was
Analysis of drug markets - Food and Drugs
of tramadol almost comparable among men with 2.3
Authority, Ghana. Available at https://www.
unodc.org/wdr2018
In the past years, the non-medical use per cent and women with 2.5 per cent.
of tramadol has been increasing in West High prices of traditional opioids such as
6Volume 21
database in the first six months of 2017 deaths. Available at: https://www.canada.
AMERICAS alone. Among the fentanyl analogues, ca/en/health-canada/services/substance-
use/problematic‚-prescription-drug-use/
the number of reports for the highly
opioids/data-surveillance-research/harms-
United States: Rising number of toxic carfentanil increased from 1,251 in deaths.html
deaths caused by fentanyl and 2016 to 2,268 in 2017 while methylfen-
fentanyl analogues tanyl, furanylfentanyl, and acrylfentanyl
Mexico: Clandestine fentanyl
have also been rising in prominence. In
Overdose deaths caused by opioids in January 2019, a large seizure of 115 kg
laboratory dismantled in
the United States have reached epi- fentanyl and 179 kg methamphetamine, Mexico City
demic levels due to counterfeit pills was made at the border between the In December 2018, a clandestine lab-
(containing varying amounts of fentanyl United States (Arizona) and Mexico. oratory that allegedly produced the
and fentanyl analogues), adulterated synthetic opioid fentanyl in Mexico
heroin and other non-opioid drugs. Centers for Disease Control and Preven-
tion (2018), Health Alert Network: Rising City was dismantled. In the laboratory,
Opioid overdose deaths quadrupled Numbers of Deaths Involving Fentanyl and pills, automated pill presses as well as
from 8,050 cases in 1999 to 33,091 cases Fentanyl Analogues, Including Carfentanil, containers filled with an unknown sub-
in 2015 and doubled in 2016 to over and Increased Usage and Mixing with stance were seized. In connection with
60,000 cases. Furthermore, the United Non-opioids. Available at: https://con-
the raid four suspects were detained. In
States National Center for Health Sta- tent.govdelivery.com/accounts/USCDC/
bulletins/1fdd9bf 2018, several seizures of fentanyl pills
tistics (NCHS) indicated that more than amounting from hundreds to thousands
55 per cent (27,000 cases) of opioid U.S. Customs and Border Protection (2019),
of pills were made by the Mexican Fed-
overdose deaths involved synthetic Press release: CBP Officers Seize Largest
Amount of Fentanyl in CBP History. Avail- eral Police. Also, in 2019, a seizure of
opioids in the 12-month period ending 1000 fentanyl pills has already been
able at: https://www.cbp.gov/newsroom/
November 2017. The rise in opioid local-media-release/cbp-officers-seize- made in the state of Baja California,
overdose deaths started with increased largest-amount-fentanyl-cbp-history which were hidden in a DVD player.
prescribing of opioids in the 1990s, fol-
lowed with rapid increases in overdose Procuraduría General de la República
deaths involving heroin from 2010 and Canada: The majority of opioid- (2018), Comunicado PGR 34/18. PGR
related deaths involve fentanyl asegura en la Ciudad de México laboratorio
significant increases in overdose deaths clandestino para elaborar fentanilo. Avail-
involving synthetic opioids (fentanyl and or fentanyl analogues able at: https://www.gob.mx/pgr/prensa/
analogues) from 2013. comunicado-pgr-34-18-pgr-asegura-en-
According to the Canadian National la-ciudad-de-mexico-laboratorio-clandes-
O’Donnell, J. K., Gladden, R. M., & Seth, P. Report on apparent opioid-related tino-para-elaborar-fentanilo
(2017), Trends in Deaths Involving Heroin deaths, the opioid crisis has affected
and Synthetic Opioids Excluding Metha- Secretaría de Seguridad y Protección Ciu-
every part of the country, but there are dadana (2019), En Baja California, Policía
done, and Law Enforcement Drug Product
clear differences in death rates and the Federal localiza mil pastillas de aparente
Reports, by Census Region — United
States, 2006–2015. MMWR Morbidity and substances involved across provinces fentanilo dentro de un dvd. Available
Mortality Weekly Report, 66(34), 897–903. and territories. In 2016, there were at: https://www.gob.mx/sspc/prensa/
2,946 apparent opioid-related deaths en-baja-california-policia-federal-localiza-
Centers for Disease Control and Preven- mil-pastillas-de-aparente-fentanilo-dentro-
tion (2018), Health Alert Network: Rising in Canada and another 3,998 were de-un-dvd
Numbers of Deaths Involving Fentanyl and reported in 2017, corresponding to an
Fentanyl Analogues, Including Carfentanil, annual death rate of 10.9 per 100,000
population in 2017. Most of the opioid-
ASIA
and Increased Usage and Mixing with
Non-opioids. Available at https://con- related deaths in 2017 occurred in the
tent.govdelivery.com/accounts/USCDC/
bulletins/1fdd9bf
province of British Columbia with 1,470
cases, followed by Ontario (1,263) and China: Fentanyl and fentanyl
Centers for Disease Control and Preven- Alberta (759). The majority of opioid- analogues are placed under
tion (2018), Understanding the Epidemic. national control
related deaths involved fentanyl or
Available at: https://www.cdc.gov/
drugoverdose/epidemic/index.html fentanyl analogues and 92 per cent were
The Chinese government has added
accidental (unintentional). Most acci-
various chemicals to the list of sub-
dental apparent opioid-related deaths
United States: Increasing occurred among males (76 per cent) and
stances regulated by the “Administrative
number of drug samples Measures on Narcotics and Psychotro-
among individuals between 30 and 39
containing fentanyl and pic Substances without Medical Use”.
years (27 per cent).
fentanyl analogues These include acrylfentanyl, carfentanil,
Government of Canada (2018), Public furanylfentanyl and valerylfentanyl and
Drug submissions to the United States Health Agency of Canada - “National more recently two other synthetic opi-
report: Apparent opioid-related deaths
National Forensic Laboratory Informa- oids, U-47700 and MT-45. In August
in Canada” (2017). Available at: https://
tion System (NFLIS) testing positive for www.canada.ca/en/public-health/ 2018, China placed the recently inter-
fentanyl and fentanyl analogues have services/publications/healthy-living/ nationally controlled fentanyl analogues
doubled from 14,440 in 2015 to 34,119 national-report-apparent-opioid-related- 4-FIBF and THF-F under control.
in 2016. The trend seems to continue deaths-released-march-2018.html
Chinese Ministry of Public Security (2017),
with 25,460 reports for fentanyl and Government of Canada (2018) Overview of Notice on Inclusion of Four Fentanyl
fentanyl analogues recorded in the national data on opioid-related harms and Substances, Such as Fentanyl, in the
7GLOBAL
SMART
UPDATE
Supplement to the Catalog of Non-Medical as nasal sprays containing acrylfentanyl,
Narcotic Drugs and Psychotropic Sub- Spain: Fentanyl analogues
furanylfentanyl, 4-fluoroisobutyrfen-
stances Control, March 1, 2017. tanyl, tetrahydrofuranylfentanyl and
identified in crypto market-
China National Narcotics Control carfentanil.
sourced heroin products
Commission (2018), Original legislation. Findings of a project conducted by the
• 38 substances reported since
2009, including 28 fentanyl Spanish non-governmental organization
India: 100 kg fentanyl seizure derivatives ABD (Asociación Bienestar y Desarrollo),
A 100 kg fentanyl seizure was made in • 13 substances reported for the which provides drug checking services to
India in December 2018 in the vicinity first time in 2017, including 10 inform users about the composition of
of Mumbai Airport. The fentanyl was fentanyl derivatives the drugs, show that fentanyl analogues
meant for onward trafficking, report- • November 2015 to February 2017: such as furanylfentanyl, 4-fluorobutyr-
edly to a North American country. Four 23 deaths attributed to furanylfen- fentanyl and cyclopropylfentanyl have
people were arrested in connection with tanyl (Estonia, Finland, Germany, been identified in samples sold as heroin
the case. Sweden, United Kingdom and in crypto markets between June 2014
Norway) and April 2018. As reported by users of
The Times of India (2018), Mumbai International Drug Checking Services,
Police seize Fentanyl drug valued at • April to December 2016: 47
Rs 1,000 crore, 4 held - 28 December deaths attributed to acrylfentanyl who had submitted these samples for
2018. Information confirmed by the (Sweden, Estonia and Denmark) the study, heroin containing fentanyl
UNODC Regional Office for South Asia, analogues were acquired over crypto
New Delhi, India. Available at: https:// UNDOC (2018), World Drug Report 2018 markets from vendors located in France,
timesofindia.indiatimes.com/city/ - Analysis of drug markets. Available at: Ireland, Malta, Spain and the United
mumbai/mumbai-police-seize-fentanyl- https://www.unodc.org/wdr2018 Kingdom.
drug-valued-at-rs-1000-cr-4-held/
articleshow/67288434.cms European Monitoring Centre for Drugs Energy Control International (2018),
and Drug Addiction (2018), Euro- Fentanyl and fentanyl derivatives (1):
pean Drug Report 2018: Trends and Adulterated heroin samples from
Japan: Increase in fentanyl Developments. Available at: http:// cryptomarkets. Available at: https://ener-
analogues www.emcdda.europa.eu/system/ gycontrol-international.org/wp-content/
files/publications/8585/20181816_ uploads/2018/05/ECINT001_Heroin_
Recently, in Japan, a country with low TDAT18001ENN_PDF.pdf Adult_CRYPTMK.pdf
opioid use, several cases of intoxica-
tion with fentanyl analogues have
been reported. A fatal intoxication Estonia: Fentanyl continues to
was reported due to the use of acetyl be the most abused opioid
fentanyl. This marks the first report of In Estonia, fentanyl has long been OCEANIA
synthetic opioid insufflation rather than regarded as the most frequently misused
intravenous administration. According to opioid. It first appeared in the Estonian Australia: Rates of opioid
the forensic autopsy report, the death drug market in 2002. In 2012, the Esto- deaths and opioid poisoning
was classified as an accident. nian Drug Treatment Database identified hospitalisations increased in
Takase, Izumi, et al. (2016), An autopsy 449 primary fentanyl/3-methylfentanyl the past 10 years
case of acetyl fentanyl intoxication caused users among all 516 registered clients
A report published by the Australian
by insufflation of ‘designer drugs’, Legal (87 per cent). Fentanyl users constituted
Medicine 21 (2016): 38-44. Institute for Health and Welfare on
107 of the 125 clients entering treat-
opioid use and its associated harms
ment for the first time (86 per cent), in
showed that between 2007–08 and
the same year. Data from specialised
2016–17, there was a 25 per cent rise
treatment centres in Estonia indicate
EUROPE that opioids (mainly illicit fentanyl or
in the rate of hospitalisations due to
opioid poisoning. In 2016, opioid deaths
3-methylfentanyl) were the most com-
accounted for 62 per cent of all drug-
Europe: NPS with opioid monly reported primary substances for
induced deaths. From 2007 to 2016,
effects in the region first-time clients entering treatment in
the rate of opioid deaths increased by
2016. Nearly 70 per cent of all treatment
The first emergence of new synthetic 62 per cent, from 2.9 to 4.7 deaths per
clients, whose primary substance of use
opioids was recorded in Europe in 2009. 100,000 population. This was driven by
was an opioid, reported injecting as their
Although the use of heroin and mor- an increase in accidental opioid deaths
main route of administration.
phine, continues to be the predominant and in pharmaceutical opioid deaths.
problem, an increased number of new Mounteney, J., Giraudon, I., Denissov, G., & In 2016, non-medical use of opioids of
synthetic opioids as well as attributable Griffiths, P. (2015), Fentanyls: Are we miss- respondents aged 14 and older was at
ing the signs? Highly potent and on the rise
intoxications and fatalities have been 10.5 per cent for life-time use and 3.7
in Europe. International Journal of Drug
reported from Western and Central Policy, 26(7), 626–631. per cent for past-year use, compared to
Europe. Most of these adverse events the use in 2007 with 5.8 per cent and 2.8
European Monitoring Centre for Drugs
were reported among high-risk opioid per cent respectively. Data from waste-
and Drug Addiction (2018), Country Drug
users. Opioid related products have Report 2018 – Estonia. Available at: http:// water analysis also shows an increase
been seized in various forms (e.g. pow- www.emcdda.europa.eu/countries/drug- of fentanyl use. A comparison of data
ders, tablets, liquids) and more recently reports/2018/estonia/drug-use_en from April 2017 and April 2018, indicates
8Volume 21
that population-weighted averages for as activities to promote use and access Options for response to
fentanyl use in regional sites more than to opioids for medical and scientific
doubled. purposes, while preventing misuse and
address the opioid crisis
Australian Institute for Health and Welfare diversion. The strategy seeks to work There is a continuous international
(2018), Opioid harm in Australia: and with a wide range of United Nations debate on how to best address the
comparisons between Australia and partners, including the World Health challenges posed by the non-medical
Canada, Cat. no. HSE 210, Canberra. Organization (WHO), the International use of opioids, including synthetic
Available at: https://www.aihw.gov. Narcotics Control Board (INCB) and
au/getmedia/605a6cf8-6e53-488e- opioids, which has been strongly
other international and regional orga-
ac6e-925e9086df33/aihw-hse-210.pdf. supported and facilitated by UNODC.
aspx?inline=true nizations, academia and civil society.
As indicated in the Commission on
Australian Criminal Intelligence Commis- More information and updates on events Narcotic Drugs Resolution 61/8,
sion (2018), National Wastewater Drug and activities is available at: https://www.
unodc.org/unodc/en/opioid-crisis/index. UNODC was invited “to continue to
Monitoring Program – Report 5, August
2018. Available at: https://acic.govcms. html act as the coordinating entity within
gov.au/sites/g/files/net3726/f/nwdmp5. the United Nations system on efforts
pdf?v=1538721816 WHO: Expert Committee on to implement activities to address
Drug Dependence acknowledges the challenges posed by non-medical
New Zealand: Non-medical use increasing tramadol abuse in low use of synthetic opioids”. The options
of fentanyl is increasing and middle-income countries for response provided below relate
There are indications of non-medical use to the outcomes of the Fifth WHO-
The WHO Expert Committee on Drug
of fentanyl in New Zealand, both inten- UNODC Expert Consultation on NPS11
Dependence (ECDD) critically reviewed
tionally and through fentanyl sold as tramadol in 2018 and expressed con-
(September 2018) and the Intergov-
heroin or heroin laced with fentanyl. The cern about the increasing evidence of ernmental Expert Group Meeting on
New Zealand Police reported some fen- tramadol abuse in a number of coun- the international challenges posed
tanyl seizures that were made through tries in diverse regions, in particular the by the non-medical use of synthetic
interdiction in international mail. The widespread abuse of tramadol in many opioids12 (December 2018).
drug checking service “KnowYour- low- and middle-income countries. The
StuffNZ”, detected fentanyl at a music ECDD further acknowledged the evi- National and international
festival in February 2018, which was dence of public health risks associated control measures
sold as a white powder presumed to with tramadol abuse, which warranted
be heroin. To enable an assessment The challenge of the non-medical use
consideration of scheduling. However,
of the prevalence of use of fentanyl, tramadol was not recommended for
of synthetic opioids is not limited to
the substance has been added to the scheduling to the Commission on Nar- the ongoing opioid overdose deaths
wastewater pilot programme of the New cotic Drugs due to possible adverse in North America, but extends to all
Zealand Police in May 2018. impacts in accessing this medication, other parts of the world. However,
New Zealand Police (2017), Waitemata especially in countries where tramadol there is regional and national diver-
Police and Customs pleased with suc- may be the only available opioid analge- sity in the type of substances used.
cess of Operation Tiger. Available at: sic or in crisis situations where there is Countries have often adapted their
http://www.police.govt.nz/news/release/ very limited or no access at all to other legislative frameworks to respond
waitemata-police-and-customs-pleased-
success-operation-tiger-photos
opioids. Tramadol has been considered to specific challenges, but the dif-
for critical review by the ECDD five ferences in the control status of
times: in 1992, 2000, 2002, 2006 and synthetic opioids between countries
2014 and pre-reviewed in 2017. can create opportunities for the illicit
INTERNATIONAL WHO Expert Committee on Drug Depen- manufacture and trafficking of such
dence (2018), Critical Review Report: substances. Criminal organizations
UNODC: Leading the Tramadol. Available at: http://origin.who. exploit legislative loopholes to target
int/medicines/access/controlled-sub-
international response to the stances/Tramadol.pdf
global opioid crisis
11 WHO and UNODC (2018), Meeting Report:
The challenge of the non-medical use Fifth WHO–UNODC Expert Consultation
of synthetic opioids is not limited to on New Psychoactive Substances - Addressing
the challenges of non-medical use of opioids.
the ongoing opioid overdose deaths Available at: http://www.unodc.org/pdf/
in North America but has extended to opioids-crisis/Meeting_Report_24-25_Sep-
a global crisis. UNODC is leading the tember_2018_Fifth_WHOUNODC_Expert_
Consultation_on_New_Psychoactive_Sub-
interagency response to the crisis with stances_Addressing_the_challenges_of_non-
a multi-pronged Integrated Strategy. medical_use_of_opioids.pdf
The initiative combines early warning 12 UNODC (2018), Report on the meeting of
and trend analysis with national forensic the intergovernmental expert group on the
and counternarcotic capacity building, international challenge posed by the non-med-
ical use of synthetic opioids held in Vienna on
international law enforcement opera- 3 and 4 December 2018. Available at: https://
tions, prevention and treatment as well undocs.org/en/UNODC/CND/EG.1/2018/2
9GLOBAL
SMART
UPDATE
countries without appropriate legis- detection and interdiction extremely UNODC launched its Early Warning
lation, often through internet sales difficult, especially due to the sheer Advisory on NPS (EWA)13 in June
and trafficking by postal services. number of packages that cross 2013 as an Internet-based knowl-
Therefore, international controls of borders every day and requires inter- edge and monitoring platform in
substances are imperative. Eleven national cooperation and innovative, the framework of its Global Synthet-
substances with opioid effects have specialized techniques to disrupt ics Monitoring: Analysis, Reporting
been scheduled by the Commission illicit supply chains. Unfortunately, and Trends (SMART) Programme.
on Narcotic Drugs between 2015 to many countries continue to face The EWA enables UNODC to share
2018. major challenges in identifying and technical information for NPS iden-
detecting synthetic opioids. This tification and detection, and at the
National as well as international limited capacity impedes the moni- same time supports the work of the
control measures of synthetic opi- toring, trend analysis and reporting, WHO Expert Committee on Drug
oids should be adopted to reduce needed for developing informed law Dependence (ECDD) in identifying
their availability for non-medical enforcement and health interven- the most harmful, prevalent and
use. Given the diversity of synthetic tions and implementing national and persistent substances for potential
opioids on the global drug market, international controls. scheduling. Recent enhancements
there is a need to prioritize the to the EWA enables the collection,
most harmful, prevalent and per- The identification and detection of analyses and sharing of informa-
sistent substances for international emerging synthetic drugs, includ- tion on harm and adverse health
control in order to provide appro- ing synthetic opioids, is a necessary consequences, including fatalities,
priate, timely and effective controls. first step in any successful law associated with the use of NPS at the
Successful implementation of these enforcement or health intervention, global level.
international scheduling decisions, therefore capacities of laboratories
with tangible results on the ground, and law enforcement have to be Regional and national efforts should
would require timely incorporation enhanced. Modern analytical tech- be invested in early warning systems
into national legislative frameworks nologies, including applications or similar surveillance systems to
and cooperation between source, of Raman spectroscopy, are non- enable early detection and provide
transit and destination countries. destructive, offer improved field timely responses to the emerging
Further, such controls also imply identification capacity and limit threats of synthetic opioids. EWS
inter alia limitations to medical and the exposure of frontline officers to play a key role in the monitor-
scientific use, licences and controls potentially hazardous effects in han- ing, early detection of, and timely
regarding manufacture, trade and dling of some of these substances. responses to emerging drug threats,
distribution, import and export. Due Further development and applica- including their potential harms to
to the lack of adequate access to tions of modern field identification public health. Enhancing coopera-
opioid analgesics for pain relief and technologies and improved detec- tion between national, regional and
palliative care, proper access to con- tion of synthetic opioid packages international monitoring systems will
trolled medicines has to be ensured in the postal system will go a long ensure better understanding of the
for those in need. way in disrupting the flows of these current phenomenon and enhance
harmful substances. the development of more effective
Identification and detection of responses, due to the transnational
synthetic opioids Early warning systems nature of the synthetic drugs issue
Due to their extreme potencies, The synthetic drugs market is very being of global nature.
most synthetic opioids, including dynamic with many substances
fentanyl and its analogues are often surfacing the market every year. Public health and prevention
present in trace amounts in drugs/ Monitoring is paramount to under-
The current crisis in North America is
preparations available on the illicit standing synthetic drug markets and
mainly attributed to the non-medical
drug market. This can make their informs the development of effective
use of clandestinely manufactured
detection and identification for policies and responses. Several coun-
fentanyl, fentanyl analogues and tra-
frontline law enforcement personnel tries have already adopted strategies
madol. The use of pills and powders
and forensic laboratories extremely to enable monitoring of substances.
containing these substances amplify
challenging. In addition, with only a In terms of regional monitoring
the negative health risks, because
few grams often needed to produce systems, the early warning system
such products lack quality control,
thousands of doses, the synthetic (EWS) of the European Monitoring
are typically not portioned in precise
opioids are easy to conceal and Centre for Drugs and Drug Addic-
smuggle, often through national/ tion (EMCDDA) is an example of
international mail or express con- regional cooperation in the use of 13 UNODC (2013) Early Warning Advisory on
signment shipments. This makes early warning. At the global level, NPS. Available at: www.unodc.org/nps
10Volume 21
doses, and can be deadly in minus- and scientific purposes are not nega-
cule amounts due to the extreme tively impacted on by measures to
potencies. Often these products are prevent non-medical use and abuse.
found as contaminants in cocaine,
MDMA and methamphetamine or Innovative investigative techniques
sold as heroin, together with heroin will be required, including for the
or as counterfeit prescription drugs, monitoring and disruption of illicit
without the user’s knowledge. This manufacture and of online market-
leads to a high risk of unintentional ing, sales and distribution and related
exposure to dangerous synthetic financial flows via the Internet and
opioids and presents a risk to public dark web, in order to exchange vital
health. intelligence and information to facili-
tate a multilateral response.
Information sharing and promot-
ing good practises, both in terms of
use trends and for prevention and
treatment interventions are essen-
tial to reduce non-medical use of
synthetic opioids and prevent over-
dose deaths. To protect the health
of users, and in particular prevent
overdose deaths, there is a need for
adequate access to prevention and
treatment services, including opioid-
overdose reversing medicines such
as naloxone, and opioid substitution
therapies. The rational prescribing of
opioids in line with evidence-based
guidelines, effective risk communica-
tion strategies, removal of stigma to
ensure unhindered access to treat-
ment of opioid use disorders, and
the sharing of best practices and
trend analyses information, will
continue to play an important part
of the public health response to the
opioid crisis.
The way forward
There is no single solution to the
challenge posed by the non-medi-
cal use of synthetic opioids. It is an
international challenge and requires
multilateral cooperation to reduce
demand and counter illicit manu-
facture and trafficking. To address
the harms associated with such use,
all policy levers will be required to
promote a holistic, evidence-based,
balanced and multidisciplinary
approach, which addresses public
health and safety, and encompasses
both demand and supply reduction
initiatives. Opioids continue to play
an essential role in medicine and
it is critical that efforts to promote
access and availability for medical
11Recent Global SMART Publications
ANALYS
DRUG IS OF
M
Opiates, ARKETS
synthetic cocaine, can
drugs nabis,
Y
MMAR
IVE SU
EXECUT SIONS AND NS
CONCLUIMPLICATIO
POLICY
WORL
DRUGD
2018
REPORT
3
1
2018
WORLD
G
DRURT
REPO
Global SMART Global SMART World Drug Report Terminology and
Update Volume 20 Update Volume 19 2018 Information on Drugs 2016
(English and Spanish) (English, Spanish and Russian) (now in Spanish)
Оценка ситуации с
синтетическими наркотиками в
Центральной Азии
Отчет Глобальной программы SMART
УПН ООН
Декабрь 2017 г.
Central Asia Synthetic Synthetic Drugs in East and Global Synthetic Early Warning Advisory
Drugs Situation Assessment South-East Asia - Trends and Drugs Assessment Newsletters Volume
2017(now in Russian) Patterns of Amphetamine- - Amphetamine-type 15, 16 and 17
type Stimulants and NPS 2019 stimulants and NPS 2017
Global SMART UNODC Early Warning
Publications Advisory on NPS
Contact details
Global SMART Programme
Vienna International Centre www.unodc.org/unodc/en/scientists/smart-new.html
P.O. Box 500 www.unodc.org/nps
A-1400, Vienna www.apaic.org
Austria
unodc-globalsmart@un.org
UNODC would like to acknowledge the partners DEA, EMCDDA, INCB and WCO for their contributions to the UNODC EWA.
UNODC would like to thank the following Governments for their
financial contributions to the Global SMART Programme.
Australia Canada China Japan New Zealand
Republic of Korea Russian Federation Thailand United Kingdom United StatesYou can also read
